Identification Number:
CJB 23-00
Intended Audience:All Office of Hearings Operations (OHO) Personnel
Originating Office:Office of Hearings Operations
Title:Guidance for Manually Editing Substantial Gainful Activity (SGA) Findings in Unfavorable Adult and Child Decision Templates
Type:Chief Judge Bulletins
Program:Disability
Link To Reference:See References at the end of this CJB.
 
Retention Date: June 18, 2023

Descriptive Summary: The purpose of this Chief Judge Bulletin (CJB) is to remind Administrative Law Judges (ALJs) and decision writers that some cases will require manual edits to SGA findings in adult and child unfavorable decision templates generated through the Hearings and Appeals Case Processing System (HACPS) and the Findings Integrated Templates (FIT). These situations typically arise when fewer than 12 months have passed since the claimant last engaged in SGA.

The HACPS and FIT templates produce Step 1 denials in situations where the claimant engaged in SGA after the alleged onset date and, at the time of the decision, 12 months have not yet passed. The templates, therefore, leave the most recent months as an unadjudicated period. In some cases, such an unadjudicated period could also erroneously result in a denial in situations where a partially favorable decision with a later onset date may be more appropriate.


Policy Reminders

The basic definition of disability for adults is "the inability to do any [SGA] by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months" (emphasis added). 20 CFR §§ 404.1505 and 416.905. The basic definition of disability for children contains the same duration requirement. 20 CFR § 416.906.

Accordingly, we must assess not only whether the adult claimant's inability to do any SGA or a child’s "marked and severe functional limitations" because of a medically determinable impairment (MDI) lasted 12 continuous months, but also whether it can be expected to last 12 continuous months or to result in death. We use the applicable sequential evaluation process to determine whether an adult or child is disabled. See 20 CFR §§ 404.1520, 416.920, and 416.924.

      NOTE: There are different rules for determining disability for individuals who are statutorily blind for Title II purposes. See 20 CFR §§ 404.1581 through 404.1587. There are also different rules for determining disability for widows, widowers, and surviving divorced spouses for monthly benefits for months prior to January 1991. See 20 CFR §§ 404.1577, 404.1578, and 404.1579. Each of these different rules similarly contains the duration requirement either explicitly or by reference. Only the rules for determining disability for individuals who are blind for Title XVI purposes do not contain any duration requirement. See 20 CFR § 416.983 and SSR 82-52.
By working, an individual may demonstrate the ability to engage in SGA, at least for the time worked. However, a finding that work was not SGA during a particular period does not answer the ultimate question of ability to engage in SGA. To answer this question, we must consider all the medical and vocational evidence. According to the regulations, if the claimant is not engaged in SGA, we must then determine whether the claimant has a medically determinable physical or mental impairment. 20 CFR §§ 404.1520, 404.1521, 416.920, and 416.921; POMS DI 24001.010.

Generally, we cannot find an individual disabled prior to the date such person last engaged in SGA, except in statutory blindness cases and cases where there was no SGA for at least 12 months. POMS DI 24001.010B; DI 25501.210A.3. However, disability may be established beginning on the last day a claimant engaged in SGA, even if 12 subsequent months have not yet elapsed. Accordingly, our decisions must continue through the sequential evaluation for all periods during which the claimant did not perform SGA for at least 12 continuous months, including cases in which 12 months have not yet elapsed since the date the claimant last performed SGA.
      NOTE: Denial for insufficient duration is applicable when (1) the impairment was or is of such severity that the claimant is unable to engage in any SGA, but (2) by the end of 12 months, the impairment is, or will be, no longer of such severity as to prevent SGA. Therefore, the duration requirement is not an issue in the disability decision unless the claimant’s impairment is severe and prevents SGA. Denials for insufficient duration should also not be understood as independent of the sequential evaluation process. See SSR 82-52 and POMS DI 25505.030.

SGA Findings in HACPS and FIT Decision Templates

As a reminder, all decision writers are responsible for drafting legally sufficient decisions that are supported by the evidence and address all aspects of the claims assigned to them, ensuring decisions are consistent with the Social Security Act and with the agency's regulations, rulings, and other policies. Decision writers will need to tailor the decision to the facts of the case as appropriate and are responsible for ensuring the decision analysis is accurate.

The current HACPS and FIT templates produce Step 1 denials in situations where the claimant engaged in SGA after the alleged onset date and 12 months have not yet passed. Therefore, these templates leave the most recent months as an unadjudicated period. In some cases, such an unadjudicated period could also erroneously result in a denial in situations where a later onset date may be more appropriate.

Because HACPS and FIT unfavorable adult and child decision templates do not currently capture periods without SGA lasting less than 12 continuous months, decision writers will need to make manual edits to these decisions as appropriate per policy and the case facts.

Below, we provide tips for making the edits until the template language can be updated.

Current Decision Template Logic

The current Step 1 logic for unfavorable adult and child decisions is the same in both FIT and HACPS. However, since all decision types available in HACPS should be drafted using HACPS, below we illustrate the logic using only images from HACPS. See Standard Hearings Operations Procedure (SHOP) 6.2.1.

For the unfavorable adult and child decisions, HACPS and FIT ask the user generating the decision template a series of questions at Step 1 of the sequential evaluation.

First, the user is prompted to answer "Yes" or "No" regarding whether there is work after the onset date.




If the user selects "Yes," the user is then prompted to select whether the work after onset is "SGA," "Not SGA," or "UWA."



If the user selects "SGA," the user then must select "Yes" or "No" regarding whether there is a "continuous period of SGA from the AOD through the date of the decision."


If the user selects "No" to this question, the user is then prompted to select "Yes" or "No" regarding whether there was a continuous 12-month period during which the claimant did not engage in SGA.

Selecting "No" to this question will generate a Step 1 denial decision template that does not address periods without SGA, which last less than 12 continuous months.


Edits to Ensure Policy Compliance

To address periods without SGA that have lasted less than 12 continuous months most efficiently, the user generating an adult or child unfavorable decision should select "Yes" when asked whether there was a continuous 12-month period during which the claimant did not engage in SGA. This option will allow the user to continue through the sequential evaluation process instead of generating a Step 1 denial decision.

The decision writer must then manually edit the decision template to reflect the decision findings and specific case facts accurately.

For example, finding 3 in both the child and the adult template will state that "there has been a continuous 12-month period(s) during which the claimant did not engage in substantial gainful activity."

The decision writer must edit this finding to remove the "continuous 12-month period" language as applicable and to specify the beginning and end dates of all periods without SGA.



Additionally, when using the unfavorable adult decision template for denials based on insufficient duration, the decision writer should follow the policy in SSR 82-52, which provides that all cases denied on the basis of insufficient duration must state clearly in the denial rationale that within 12 months of onset, there was or is expected to be sufficient restoration of function so that either:
      a) there is or will be no significant limitation of the ability to perform basic work-related functions; or

      b) in spite of significant remaining limitations, the individual should be able to do past relevant work or otherwise engage in SGA, considering pertinent vocational factors.


Also see HALLEX I-2-8-20 and HALLEX I-2-8-25 for general reminders concerning decision writing instructions and decision drafting.

Direct all program–related and technical questions through your management chain. Regional Office staff may direct questions about this matter to the Office of the Chief Administrative Law Judge, Division of Field Procedures.


References:

20 CFR 404.1505 and 416.905: Basic definition of disability for adults

20 CFR 404.1520 and 416.920: Evaluation of disability of adults, in general

20 CFR 404.1521 and 416.921: Establishing that you have a medically determinable impairment

20 CFR 404.1581 through 404.1587: Blindness

20 CFR 404.1577, 404.1578 and 404.1579: Widows, Widowers, and Surviving Divorced Spouses

20 CFR 416.906: Basic definition of disability for children

20 CFR 416.924: How we determine disability for children

SSR 82-52: Titles II and XVI: Duration of the Impairment

HALLEX I-2-8-20: Decision Writing Instructions

HALLEX I-2-8-25: Writing the Decision

POMS DI 24001.010: Effect of SGA on Disability Status

POMS DI 25501.210: Alleged Onset Date

POMS DI 25505.030: Evaluation of the Duration Requirement for Disability

SHOP 6.2.1

CJB 23-00 - Guidance for Manually Editing Substantial Gainful Activity (SGA) Findings in Unfavorable Adult and Child Decision Templates - 01/18/2023